Provider Demographics
NPI:1982478657
Name:MORE LIFE CHIROPRACTIC & WELLNESS
Entity Type:Organization
Organization Name:MORE LIFE CHIROPRACTIC & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDALES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:575-937-6667
Mailing Address - Street 1:1702 GOODFIELD LN
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-3963
Mailing Address - Country:US
Mailing Address - Phone:575-937-6667
Mailing Address - Fax:
Practice Address - Street 1:7214 HIGHWAY 78 STE 14
Practice Address - Street 2:
Practice Address - City:SACHSE
Practice Address - State:TX
Practice Address - Zip Code:75048-2502
Practice Address - Country:US
Practice Address - Phone:469-626-7360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1013599075Medicaid
TX1023602406Medicaid